Registration: Fitting in, Standing Out - 6th - 8th grade (Sep 29, 2017 - Oct 1, 2017 )

USER INFORMATION
First Name:
Last Name:
Address:
1
City:
State:
Zip:
Email:
Phone:
Gender:
Birth Date:
select your current grade:
1
Parents' names:
Parents e-mails:
1
FOOD: Check any of these restrictions that apply (you may explain details in the next box):
vegetarianveganallergy-specify belowno gluten
Explain any specific food needs or things that the cook should know:
1
The following information I have given here is new:
mailing addressphone numbere-mailfood needs
Your Quaker meeting or other faith community:
1
Note any other concerns we should be aware of (health, accesibility, etc.):
1
TRANSPORTATION: Would you like to be included on the carpool list? The list is sent to people who are on it.:
yes  no  
I am planning to arrive by train and would like to be on a list of people willing to share a taxi:
Hudson Amtrak (from NYC)  Albany Amtrak (from the west)  
1
MONEY : The deposit amount will appear automatically on the confirmation page. You may change the amount by typing in what you want to pay at this time (above the minumum deposit).
I would like the first time attender youth discount:
yes  
1
My monthly meeting will pay for my registration:
Ithaca - youth conference  
Rahway- Plainfield - all ages  
other meeting (put meeting name and amount in the comment box)  
1
Enter the amount of financial aid you are requesting from Powell House:
1
I am making a donation to help offset the actual cost of youth conferences:
$25  $50  $75  $100  $125  
1
Please note here anything else we should know.:

Powell House is the conference and retreat center of the 

New York Yearly Meeting of the Religious Society of Friends (Quakers).

Powell House
524 Pitt Hall Rd
Old Chatham,  NY
12136
phone  518-794-8811
fax     518-794-8815
Adult Program 
sharon@powellhouse.org
regina@powellhouse.org
Youth Program
chrisandmike@powellhouse.org